Utilization of Specialty Mental Health Care Among Persons with Severe Mental Illness: The Roles of Demographics, Need, Insurance, and Risk

Health Services Research, April, 2000 by Donna D. McAlpine, David Mechanic

Objective. To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group.

Data Source. The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample.

Study Design. Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression.

Principal Findings. The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders.

Conclusions. Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill maybe exacerbated by the managed care trend to reductions in intensity of treatment.

Key Words. Severe mental illness, mental health care, psychiatric services

BACKGROUND

Severe mental illnesses (SMI) are those that are the most clinically complex and persistent. Although the specific diagnoses and illnesses that meet these criteria may be debatable, and diagnosis alone does not define the need for care (Mechanic 1999), there is consensus that schizophrenia and bipolar disorders are among the most severe mental illnesses. These disorders are often associated with severe deficits in functioning and require ongoing treatment from mental health care professionals (Harrow et al. 1997; Goldberg, Harrow, and Grossman 1995; McKay et al. 1995). The failure to engage and maintain persons with SMI in mental health treatment increases risks for hospitalization, poor social and clinical functioning, and diminished quality of life. Given limited mental health care resources, and the inherent rationality of targeting resources to those most in need, it is important to examine factors that either facilitate or impede utilization of services among persons who are the most severely mentally il l.

Data from the Epidemiologic Catchment Area (ECA) study indicate that the one-year prevalence of schizophrenic/schizophreniform disorders and bipolar disorder is just over one percent (Regier, Narrow, Rae, et al. 1993). Yet many persons with these disorders do not receive regular specialty mental health treatment. The National Comorbidity Survey (NCS) estimated that about 48 percent of persons with non-affective psychoses used specialty alcohol, drug, or mental health (ADM) outpatient services in a 12-month period, compared to a treatment rate of about 12 percent for persons with any mental disorder (Kessler, Zhao, Katz, et al. 1999). Similarly, the ECA study, based on five sites, estimated that about 46 percent of persons with schizophrenia and 32 percent of persons with bipolar disorder used specialty ADM services in a 12-month period, compared to almost 13 percent for persons with any disorder (Regier, Narrow, Rae, et al. 1993).

While the gap between need for care and use of services is well documented, we know little about the factors that increase access among persons with SMI in the general population. Most studies of access have been based on general population samples with and without disorder, or on studies of persons with any of many measured mental disorders. This research suggests that women, whites, and those with more education receive more mental health care (Howard, Cornille, Lyons, et al. 1996; Leaf, Livingston, Tischler, et al. 1985). Insurance also increases access to mental health care, with those who are insured being more likely to receive such care (Landerman, Burns, Swartz, et al. 1994; Rabinowitz, Bromet, Lavelle, et al. 1998). Contextual factors, particularly risk indicators, are also important; persons selected into specialty care are those who are more likely to be perceived by their family, social networks, and health care providers as more dangerous and disruptive (Mechanic, Angel, and Davies 1991; Sulliva n, Young, and Morgenstern 1997).